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Nosocomial Infections in the ICU*: The Growing Importance of Antibiotic-Resistant Pathogens FREE TO VIEW

David J. Weber, MD, MPH; Ralph Raasch, PharmD; William A. Rutala, PhD, MPH
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*From the Adult (Drs. Weber and Rutala) and Pediatric (Dr. Weber) Infectious Disease Divisions, University of North Carolina School of Medicine; the Department of Epidemiology (Dr. Weber), University of North Carolina School of Public Health; the Department of Hospital Epidemiology (Drs. Weber and Rutala), University of North Carolina Hospitals; and, the University of North Carolina School of Pharmacy (Dr. Raasch), Chapel Hill, NC.



Chest. 1999;115(suppl_1):34S-41S. doi:10.1378/chest.115.suppl_1.34S
Text Size: A A A
Published online

Patients hospitalized in ICUs are 5 to 10 times more likely to acquire nosocomial infections than other hospital patients. The frequency of infections at different anatomic sites and the risk of infection vary by the type of ICU, and the frequency of specific pathogens varies by infection site. Contributing to the seriousness of nosocomial infections, especially in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens. Prevention and control strategies have focused on methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and extended-spectrum β-lactamase-producing Gram-negative bacilli, among others. An effective infection control program includes a surveillance system, proper handwashing, appropriate patient isolation, prompt evaluation and intervention when an outbreak occurs, adherence to standard guidelines on disinfection and sterilization, and an occupational health program for health-care providers. Studies have shown that patients infected with resistant strains of bacteria are more likely than control patients to have received prior antimicrobials, and hospital areas that have the highest prevalence of resistance also have the highest rates of antibiotic use. For these reasons, programs to prevent or control the development of resistant organisms often focus on the overuse or inappropriate use of antibiotics, for example, by restriction of widely used broad-spectrum antibiotics (eg, third-generation cephalosporins) and vancomycin. Other approaches are to rotate antibiotics used for empiric therapy and use combinations of drugs from different classes.

Abbreviations: CDC = Centers for Disease Control and Prevention; MRSA = methicillin-resistant Staphylococcus aureus; NNIS = National Nosocomial Infections Surveillance; SHEA/IDSA = Society for Healthcare Epidemiology of America/Infectious Diseases Society of America; VRE = vancomycin-resistant Enterococcus sp

Figures in this Article

Since the 1980s, infectious disease specialists have recognized that ICU patients acquire nosocomial infections at a much higher rate than patients elsewhere in the hospital. For ICU patients, the risk is as much as 5 to 10 times greater than for those on general medical wards.1,,2,,3,,4 This increased risk of nosocomial infection results from three major factors: (1) intrinsic risk factors related to the need for intensive care, such as severe underlying disease, multiple illnesses, malnutrition, extremes of age, and immunosuppression; (2) invasive medical devices, such as endotracheal tubes for mechanical ventilation, intravascular catheters, and urinary tract catheters; (3) crowding (eg, neonatal ICU) and animate reservoirs (eg, colonized or infected patients), which increase the risk of cross-infection in the ICU.

The most representative data on nosocomial infection rates have been provided by the National Nosocomial Infections Surveillance (NNIS) system.5NNIS data indicate that today’s typical hospitalized patient may be sicker than in former years. Data from surveys of NNIS hospitals between 1988 and 1995 demonstrate a significant increase in the number of ICU beds and a slight decrease, not reaching statistical significance, in total beds.6

Surveillance data from ICUs are available for the years 1986 through 1997 (Table 1). 7 Risk adjustment is provided by stratifying the data by type of ICU and type of invasive medical device (ie, ventilator, central venous catheter, urinary tract catheter) and by presenting the infection rate as infections per 1,000 device days. Further risk adjustment has been performed for infections in neonatal ICUs by stratifying patients by birth weight.,7,,8

From the NNIS data, one may conclude the following: the relative frequency of different sites of nosocomial infections (ie, ventilator-associated pneumonia, bloodstream infections, urinary tract infections) and the absolute risk of infection (per 1,000 device days) vary by type of ICU; the relative frequency of different nosocomial pathogens varies by site of infection (Table 2); and the site-specific rates of nosocomial infections in similar types of ICUs vary 10- to 20-fold among hospitals.7

In the hospital, concern about drug-resistant pathogens has focused on methicillin-resistant Staphylococcus aureus (MRSA),9,,10 vancomycin-resistant Enterococcus sp (VRE),11,,12,,13 extended-spectrum β-lactamase-producing Gram-negative bacilli,14multidrug-resistant Mycobacterium tuberculosis,15 fluconazole-resistant Candida sp,16and most recently, strains of S aureus with reduced susceptibility to vancomycin—because such strains have now been isolated in Japan and the United States.17 This concern has been fueled by multiple reports of outbreaks of infection caused by these pathogens and increasing rates of endemic infection in ICU patients. However, only limited data are available regarding the prevalence of these pathogens in ICUs throughout the United States. Data obtained from the NNIS system documents the increasing frequency of VRE in US hospitals (Fig 1). ,17,,18 Archibald and colleagues6 reported the prevalence of drug-resistant pathogens isolated from different patient populations of eight hospitals between 1994 and 1995 (Table 3). For five of these antimicrobial/pathogen combinations, the percentage of resistant isolates was significantly higher in the ICU than in the two other settings.,6

Weinstein19 has summarized the traditional infection-control measures used in ICUs (Table 4). Unfortunately, as noted by Weinstein, these control measures often fail because frequently patients are already colonized with “nosocomial” bacteria when hospitalized and because endogenous flora in ICU patients is often amplified by antibiotics and gastric alkalization. Other factors include selection by antibiotic pressure on antibiotic-resistant bacterial subpopulations and spontaneous bacterial resistance mutation, lapses in aseptic care during a crisis, spread on hands of personnel caring for ventilator-dependent patients who have heavy respiratory tract colonization or infection, unrecognized environmental reservoirs, and new devices that break through anatomic barriers.,19

Key elements of an effective infection control program include a surveillance system,20proper hand washing before and after contact with each patient or patient equipment,21 appropriate isolation of patients with transmissible pathogens, prompt evaluation and intervention in cases of outbreaks,22 adherence to standard guidelines on disinfection and sterilization of medical equipment,23and an effective program of occupational health focusing on preexposure and postexposure management of health-care providers.24Proper hand washing, isolation, and disinfection are critical to prevent transmission of resistant pathogens between patients via contaminated equipment or contaminated hands of health-care providers. GI tract colonization of health-care providers with resistant pathogens does not appear to be a reservoir of these infectious agents.25

Consensus statements have been published recently that delineate strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals.26,,27 Prevention strategies are based on minimizing the transmission of antibiotic-resistant pathogens between patients (Tables 5 and 6) and developing a program to prevent or reduce antimicrobial resistance (Table 7). The Centers for Disease Control and Prevention (CDC) has published general isolation guidelines to minimize the risk of transmission of infectious agents from colonized/infected patients to other patients or health-care providers.,21 Detailed infection-control recommendations have been published to minimize the transmission of MRSA,28 VRE,18 and S aureus with reduced susceptibility to vancomycin.,17

Consensus guidelines define an MRSA outbreak as “an increase in the rate of MRSA cases or a clustering of new cases due to the transmission of a single microbial strain in a health-care institution, including long-term care facilities.”28 The following threshold rates (number of new nosocomial cases per 100 hospital admissions/number of new nosocomial cases per 100 patient days) for identifying high rates of MRSA transmissions are provided: < 200 hospital beds, 0.13/0.25; 200 to 499 hospital beds, 0.25/0.3; and, ≥ 500 hospital beds, 0.5/0.6. A four-phase approach to control is recommended (Table 5).

The proper use of vancomycin (Table 6)18 is especially important because vancomycin use has risen dramatically in recent years, and vancomycin use is one of the strongest risk factors for VRE colonization/infection. The CDC guidelines for preventing the spread of VRE include recommendations on the prudent use of vancomycin, an educational program on VRE for hospital personnel, routine testing of all enterococci isolated from blood and sterile body sites (except urine) for vancomycin resistance, screening of all enterococcal isolates for vancomycin resistance if VRE are detected, and appropriate use of isolation precautions for all VRE-infected or colonized patients.18

The focus on control of antimicrobial use stems from compelling evidence of a causal association between antimicrobial use in hospitals and resistance of pathogens to these antimicrobials.29 The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) guidelines point out the following: changes in the use of antibiotics parallel changes in the prevalence of resistance to them. Resistance is more prevalent in nosocomial bacterial strains than in those from the community. Hospital patients infected with resistant strains are more likely than control patients to have received prior antimicrobials. Hospital areas that have the highest prevalence of resistance also have the highest rates of use of antibiotics. The longer a patient is exposed to antimicrobials, the greater the likelihood of colonization with resistant organisms.27

Risk Factors

Multiple case-control studies have analyzed the risk factors associated with infection or colonization with MRSA or VRE. Both univariate analysis in individual case studies and multivariate analysis have demonstrated that antibiotic exposure30,,31,,32,,33 and cephalosporin use are risk factors for infection with MRSA.33,,34

To prevent or control antimicrobial resistance, the SHEA/IDSA guidelines propose the following: the selective removal, control, or restriction of antimicrobial agents or classes; the rotation of antimicrobial agents; and use of combination antimicrobial therapy. The SHEA/IDSA guidelines also review specific methods to implement antibiotic control policies (Table 8). The goal is to have all patients receive the most effective, least toxic, and least costly antibiotic for the precise period needed to cure or prevent an infection.27

Restriction of Antibiotic Use

By the early 1980s, most teaching hospitals had adopted restriction policies for the use of selected expensive agents.35Himmelberg and colleagues36 demonstrated that institution of restriction policies was associated with reduced antibiotic expenditures, but elimination of a restriction policy resulted in an increase of 103% in the cost of the previously restricted antibiotics.

In another study, implementation of a rigid protocol for the use of preoperative prophylactic antibiotics resulted in cost savings of 57%.37While antibiotic restriction policies clearly result in lower cost, the influence of these programs on the prevalence of resistance and on clinical outcomes has been less well defined. Decreased use of broad-spectrum cephalosporins has been associated temporally with decreased antibiotic resistance among Gram-negative bacilli,38,,39,,40,,41 and decreased use of third-generation cephalosporins and vancomycin has been associated with a decreased incidence of VRE.42 Investigators have also found that antibiotic control policies resulted in a stable median-length stay and a reduction in the number of nosocomial infections treated with antimicrobial drugs.37 White and colleagues43 evaluated the institution of a policy that required prior authorization for selected parenteral antibiotics. Total parenteral antimicrobial expenditures decreased by 32% and susceptibilities to all β-lactam and quinolone antibiotics increased. Importantly, for patients with bacteremia caused by Gram-negative bacilli, the restrictions did not change overall survival. Further, there were no differences in the median time from positive blood culture to the prescription of an appropriate antibiotic or in the median time to discharge from the hospital. Evans and coworkers44 developed a computerized decision-support program to assist physicians in the use of anti-infective agents. Patients who received antibiotics recommended by the computer program had significant reductions in the cost of anti-infective agents, total hospital costs, and length of hospital stay.

Substitution or rotation of antibiotics has been proposed as a method for decreasing the prevalence of antibiotic-resistant pathogens. Gerding et al45reported that substitution of amikacin for gentamicin led to a significant reduction in resistance to gentamicin and tobramycin among Gram-negative bacilli. However, the first attempt to reintroduce gentamicin led to a resurgence of gentamicin resistance. Kollef and coworkers46 replaced ceftazidime with ciprofloxacin for empiric therapy for ventilator-associated pneumonia and demonstrated a reduction in the incidence of ventilator-associated pneumonia attributed to antibiotic-resistant Gram-negative bacteria. However, limitations with this study preclude accepting its conclusion that a scheduled change of antibiotic classes can reduce the incidence of ventilator-associated pneumonia. First, the incidence of pneumonia declined for unclear reasons. Second, only a single change was evaluated rather than multiple changes. Finally, the follow-up period was only 6 months.

Nosocomial infections, especially those caused by antibiotic-resistant pathogens, represent an important source of morbidity and mortality for the patient hospitalized in an ICU. Important antibiotic-resistant nosocomial pathogens include MRSA, VRE, Gram-negative bacilli (especially, Klebsiella and Enterobacter) producing extended-spectrum β-lactamases, multiple drug-resistant M tuberculosis, and fluconazole-resistant Candida sp.

The key to control of antibiotic-resistant pathogens in the ICU is rigorous adherence to infection control guidelines and prevention of antibiotic misuse. Antibiotic restriction policies clearly result in reduced drug costs. Evidence suggests that reducing use of certain antibiotics may lead to a decreased prevalence of antibiotic-resistant pathogens: vancomycin, VRE; gentamicin, gentamicin-resistant Gram-negative bacilli; and, ceftazidime, Gram-negative bacilli producing extended-spectrum β-lactamases. Limited data suggest that measures to control antibiotic use do not adversely affect—and may actually improve—patient outcomes (eg, decreased length of stay, risk of subsequent infection).

Unfortunately, relatively few appropriately designed studies have evaluated the impact of antibiotic- and infection-control interventions on the prevalence of antibiotic resistance among nosocomial pathogens and on patient outcomes. The efficacy of intensive antibiotic control should be assessed in multicenter studies designed to avoid methodologic flaws.47Preventing the emergence of multidrug-resistant microorganisms requires the adoption of a multifaceted approach.48

Dr. Weber: I just want to go over briefly the nosocomial guidelines from the American Thoracic Society. These have a complicated scheme based on risk factors, onset of disease, etc. One of the weaknesses of the guidelines is that they just tell you to use a quinolone or a β-lactam/β-lactamase inhibitor combination. I do not think many of us would use ampicillin/sulbactam in the ICU for nosocomial pneumonia, but that would meet the American Thoracic Society guidelines. I have updated this and added specific drugs. I believe that appropriate drugs would include piperacillin/tazobactam, cefotaxime, ceftriaxone, and cefepime. If you have anaerobes, they suggest adding clindamycin. If you are worried about that, you can use piperacillin/tazobactam alone.

If the patient has severe pneumonia, then it is an aminoglycoside, ciprofloxacin, or trovafloxacin plus one of the other drugs we just mentioned. In the ICUs in general, people are going to pick one of the combinations of piperacillin/tazobactam, ceftazidime, cefepime, imipenem, or meropenem with ciprofloxacin, trovafloxacin, or an aminoglycoside. I think that is going to be the standard therapy in ICUs, plus or minus vancomycin, depending on MRSA.

So antibiotic resistance is a growing problem and control of antibiotic use is crucial, but few guidelines can aid the clinician in what interventions to use. There are very limited data demonstrating effective control measures for outcomes other than cost. Most guidelines and multiple studies suggest that vancomycin should be limited, and that an increase in cephalosporin use increases the likelihood of VRE and extended-spectrum β-lactamase. Obviously piperacillin/tazobactam is an excellent therapy for several common ICU infections, such as pneumonia, and may have a reduced risk of precipitating resistance.

Dr. Campbell: For prior authorization of an antibiotic, does the prescribing physician call the infectious disease specialist to ask, “May I use this drug?”

Dr. Weber: That is what we were doing up to about 8 years ago. The prescribing physicians would have to call the infectious diseases specialist, and then the infectious diseases specialist would ask, “Why do you want to use that?”

Dr. Campbell: This may work in a university or Veterans Affairs hospital, but once you try to move it into private hospitals—you cannot do it.

Dr. Weber: I agree that it is particularly hard in the private hospitals. Now we have moved away from prior authorization, and pharmacy has a set of guidelines as to which antibiotics should be used, depending on the clinical issues.

Correspondence to: David Jay Weber, MD, MPH, CB 7030 Burnett-Womack, 547, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7030

Table Graphic Jump Location
Table 1. Device-Associated Infection Rates by Type of ICU7
* 

Cases of ventilator-associated pneumonia per 1,000 ventilator-days.

 

Values represent the pooled mean, 10th percentile value, and 90th percentile value of hospitals reporting data to the CDC.

 

Number of infections per 1,000 central-line days.

§ 

Number of infections per 1,000 urinary-catheter days.

Table Graphic Jump Location
Table 2. Distribution of the Five Most Common Nosocomial Pathogens Isolated From the Four Major Infection Sites in the ICU, January 1986–April 19977
* 

CoNS = coagulase-negative staphylococcus.

Figure Jump LinkFigure 1.  Nosocomial Enterococcus in the United States, 1992 through 1996. From Summary of Notifiable Diseases, United States, 1996 MMWR.49Grahic Jump Location
Table Graphic Jump Location
Table 3. Resistance to Specific Antimicrobials in Isolates From Inpatients vs Outpatients for Sentinel Antimicrobial/Pathogen Combinations*
* 

Adapted from Archibald et al,6 with permission.

 

Antimicrobial-resistant isolates significantly higher in ICU than in other two settings.

 

NS = not significant.

Table Graphic Jump Location
Table 4. Traditional Infection Control Measures in ICUs*
* 

From Weinstein,19 with permission.

Table Graphic Jump Location
Table 5. Four-Phase Approach to the Management of an MRSA Outbreak*
* 

From Wenzel et al,28 with permission.

Table Graphic Jump Location
Table 6. Recommended Use of Vancomycin*
* 

Adapted from CDC.18

Table Graphic Jump Location
Table 7. Elements of an Optimal Antimicrobial Control Program to Study the Prevention or Reduction of Antimicrobial Resistance*
* 

Adapted from Shlaes et al,27 with permission.

Table Graphic Jump Location
Table 8. Methods to Implement Antibiotic Control or Restriction Policies
* 

Adapted from Shlaes et al,27 with permission.

Donowitz, LG, Wenzel, RP, Hoyt, JW (1982) High risk of hospital-acquired infection in the ICU patient.Crit Care Med10,355-357
 
Chandrasekar, PH, Kruse, JA, Matthews, MF Nosocomial infection among patients in different types of intensive care units at a city hospital.Crit Care Med1986;14,508-510
 
Brown, RB, Hosmer, D, Chen, HC, et al A comparison of infections in different ICUs within the same hospital.Crit Care Med1985;13,472-476
 
Brawley, RL, Weber, DJ, Samsa, GP, et al Multiple nosocomial infections: an incidence study.Am J Epidemiol1989;130,769-780
 
Emori, TG, Culver, DH, Horan, TC, et al National nosocomial infections surveillance system (NNIS): description of surveillance methods.Am J Infect Control1991;19,19-35
 
Archibald, L, Phillips, L, Monnet, D, et al Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit.Clin Infect Dis1997;24,211-215
 
National Nosocomial Infections Surveillance (NNIS) report. Data summary from October 1986–April 1997, issued May 1997: a report from the NNIS System.Am J Infect Control1997;25,477-487
 
Gaynes, RP, Edwards, JR, Jarvis, WR, et al Nosocomial infections among neonates in high-risk nurseries in the United States.Pediatrics1996;98,357-361
 
Boyce, JM Methicillin-resistantStaphylococcus aureus: detection, epidemiology, and control measures.Infect Dis Clin North Am1989;3,901-913
 
Mulligan, ME, Standiford, HC, Kauffman, CA Methicillin-resistantStaphylococcus aureus: a consensus review of the microbiology, pathogenesis, and epidemiology with implications for prevention and management.Am J Med1993;94,313-328
 
Murray, BE Vancomycin-resistant enterococci.Am J Med1997;102,284-293
 
Eliopoulos, GM Vancomycin-resistant enterococci: mechanism and clinical relevance.Infect Dis Clin North Am1997;11,851-865
 
Boyce, JM Vancomycin-resistant enterococcus: detection, epidemiology, and control measures.Infect Dis Clin North Am1997;11,367-384
 
Paterson DL, Ko WC, Mohapatra S, et al.Klebsiella pneumoniae bacteremia: impact of extended spectrum beta-lactamase (ESBL) production in a global study of 216 patients [abstract]. 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; Sept 28–Oct 1, 1997; Toronto, Ontario, Canada.
 
CDC.. Guidelines for preventing the transmission ofMycobacterium tuberculosisin health-care facilities, 1994.MMWR1994;43(No. RR-13),1-132
 
White, TC, Marr, KA, Bowden, RA Clinical, cellular, and molecular factors that contribute to antifungal drug resistance.Clin Microbiol Rev1998;11,382-402
 
CDC.. Update:Staphylococcus aureuswith reduced susceptibility to vancomycin—United States, 1997.MMWR1997;46,813-815
 
CDC.. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC).MMWR1994;44,1-13
 
Weinstein, RA Epidemiology and control of nosocomial infections in adult intensive care units.Am J Med1991;91(suppl 3B),179S-184S
 
Perl, TM Surveillance, reporting, and the use of computers. Wenzel, RP eds.Prevention and control of nosocomial infections 3rd ed.1997,127-161 Williams & Wilkins. Baltimore, MD:
 
Garner, JS Hospital Infection Control Practices Advisory Committee: guideline for isolation precautions in hospitals.Infect Control Hosp Epidemiol1996;17,53-80
 
Wendt, C, Herwaldt, LA Epidemics: identification and management. Wenzel, R eds.Prevention and control of nosocomial infections 3rd ed.1997,175-213 Williams & Wilkins. Baltimore, MD:
 
Rutala, WA APIC guideline for selection and use of disinfectants.Am J Infect Control1996;24,313-342
 
Bolyard, EA, Tablan, OC, Williams, WW, et al Guideline for infection control in health care personnel, 1998.Am J Infect Control1998;26,289-354
 
Carmeli, Y, Venkataraman, L, DeGirolami, PC, et al Stool colonization of healthcare workers with selected resistant bacteria.Infect Control Hosp Epidemiol1998;19,38-40
 
Goldmann, DA, Weinstein, RA, Wenzel, RP, et al Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: a challenge to hospital leadership.JAMA1996;275,234-240
 
Shlaes, DM, Gerding, DN, John, JF, Jr, et al Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.Clin Infect Dis1997;25,584-599
 
Wenzel, RP, Reagan, DR, Bertino, JS, Jr, et al Methicillin-resistantStaphylococcus aureusoutbreak: a consensus panel’s definition and management guidelines.Am J Infect Control1998;26,102-110
 
McGowan, JE Antimicrobial resistance in hospital organisms and its relation to antibiotic use.Rev Infect Dis1983;5,1033-1048
 
Law, MR, Gill, ON Hospital-acquired infection with methicillin-resistant and methicillin-sensitive staphylococci.Epidemiol Infect1988;101,623-629
 
Hershow, RC, Khayr, WF, Smith, NL A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitiveStaphylococcus aureusinfections in a university hospital.Infect Control Hosp Epidemiol1992;13,587-593
 
Coll, PP, Crabtree, BF, O’Connor, PJ, et al Clinical risk factors for methicillin-resistantStaphylococcus aureusbacteriuria in a skilled-care nursing home.Arch Fam Med1994;3,357-360
 
Washio, M, Mizoue, T, Kajioka, T, et al Risk factors for methicillin-resistantStaphylococcus aureus(MRSA) infection in a Japanese geriatric hospital.Public Health1997;111,187-190
 
Peacock, JE, Jr, Marsik, FJ, Wenzel, RP Methicillin-resistantStaphylococcus aureus: introduction and spread within a hospital.Ann Intern Med1980;93,526-532
 
Klapp, DL, Ramphal, R Antibiotic restriction in hospitals associated with medical schools.Am J Hosp Pharm1983;40,1957-1960
 
Himmelberg, CJ, Pleasants, RA, Weber, DJ, et al Use of antimicrobial drugs in adults before and after removal of a restriction policy.Am J Hosp Pharm1991;48,1220-1227
 
Gyssens, IC, Geerligs, IEJ, Dony, JMJ, et al Optimising antimicrobial drug use in surgery: an intervention study in a Dutch university hospital.J Antimicrob Chemother1996;38,1001-1012
 
Ballow, CH, Schentag, JJ Trends in antibiotic utilization and bacterial resistance: report of the National Nosocomial Resistance Surveillance Group.Diagn Microbiol Infect Dis1992;15,37S-42S
 
Bamberger, DM, Dahl, SL Impact of voluntary vs enforced compliance of third-generation cephalosporin use in a teaching hospital.Arch Intern Med1992;152,554-557
 
Jones, RN The current and future impact of antimicrobial resistance among nosocomial bacterial pathogens.Diagn Microbiol Infect Dis1992;15,3S-10S
 
Meyer, KS, Urban, C, Eagan, JA, et al Nosocomial outbreak of Klebsiella infection resistant to late-generation cephalosporins.Ann Intern Med1993;119,353-358
 
Quale, J, Landman, D, Saurina, G, et al Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci.Clin Infect Dis1996;23,1020-1025
 
White, AC, Jr, Atmar, RL, Wilson, J, et al Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes.Clin Infect Dis1997;25,230-239
 
Evans, RS, Pestotnik, SL, Classen, DC, et al A computer-assisted management program for antibiotics and other antiinfective agents.N Engl J Med1998;338,232-238
 
Gerding, DN, Larson, TA, Hughes, RA, et al Aminoglycoside resistance and aminoglycoside usage: 10 years of experience in one hospital.Antimicrob Agents Chemother1991;35,1284-1290
 
Kollef, MH, Vlasnik, J, Sharpless, L, et al Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia.Am J Respir Crit Care Med1997;156,1040-1048
 
McGowan, JE, Jr Do intensive hospital antibiotic control programs prevent the spread of antibiotic resistance?Infect Control Hosp Epidemiol1994;15,478-483
 
Jarvis, WR Preventing the emergence of multidrug-resistant microorganisms through antimicrobial use controls: the complexity of the problem.Infect Control Hosp Epidemiol1996;17,490-495
 
CDC.. Summary of notifiable diseases, United States, 1996.MMWR1997;45,1-87
 

Figures

Figure Jump LinkFigure 1.  Nosocomial Enterococcus in the United States, 1992 through 1996. From Summary of Notifiable Diseases, United States, 1996 MMWR.49Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Device-Associated Infection Rates by Type of ICU7
* 

Cases of ventilator-associated pneumonia per 1,000 ventilator-days.

 

Values represent the pooled mean, 10th percentile value, and 90th percentile value of hospitals reporting data to the CDC.

 

Number of infections per 1,000 central-line days.

§ 

Number of infections per 1,000 urinary-catheter days.

Table Graphic Jump Location
Table 2. Distribution of the Five Most Common Nosocomial Pathogens Isolated From the Four Major Infection Sites in the ICU, January 1986–April 19977
* 

CoNS = coagulase-negative staphylococcus.

Table Graphic Jump Location
Table 3. Resistance to Specific Antimicrobials in Isolates From Inpatients vs Outpatients for Sentinel Antimicrobial/Pathogen Combinations*
* 

Adapted from Archibald et al,6 with permission.

 

Antimicrobial-resistant isolates significantly higher in ICU than in other two settings.

 

NS = not significant.

Table Graphic Jump Location
Table 4. Traditional Infection Control Measures in ICUs*
* 

From Weinstein,19 with permission.

Table Graphic Jump Location
Table 5. Four-Phase Approach to the Management of an MRSA Outbreak*
* 

From Wenzel et al,28 with permission.

Table Graphic Jump Location
Table 6. Recommended Use of Vancomycin*
* 

Adapted from CDC.18

Table Graphic Jump Location
Table 7. Elements of an Optimal Antimicrobial Control Program to Study the Prevention or Reduction of Antimicrobial Resistance*
* 

Adapted from Shlaes et al,27 with permission.

Table Graphic Jump Location
Table 8. Methods to Implement Antibiotic Control or Restriction Policies
* 

Adapted from Shlaes et al,27 with permission.

References

Donowitz, LG, Wenzel, RP, Hoyt, JW (1982) High risk of hospital-acquired infection in the ICU patient.Crit Care Med10,355-357
 
Chandrasekar, PH, Kruse, JA, Matthews, MF Nosocomial infection among patients in different types of intensive care units at a city hospital.Crit Care Med1986;14,508-510
 
Brown, RB, Hosmer, D, Chen, HC, et al A comparison of infections in different ICUs within the same hospital.Crit Care Med1985;13,472-476
 
Brawley, RL, Weber, DJ, Samsa, GP, et al Multiple nosocomial infections: an incidence study.Am J Epidemiol1989;130,769-780
 
Emori, TG, Culver, DH, Horan, TC, et al National nosocomial infections surveillance system (NNIS): description of surveillance methods.Am J Infect Control1991;19,19-35
 
Archibald, L, Phillips, L, Monnet, D, et al Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit.Clin Infect Dis1997;24,211-215
 
National Nosocomial Infections Surveillance (NNIS) report. Data summary from October 1986–April 1997, issued May 1997: a report from the NNIS System.Am J Infect Control1997;25,477-487
 
Gaynes, RP, Edwards, JR, Jarvis, WR, et al Nosocomial infections among neonates in high-risk nurseries in the United States.Pediatrics1996;98,357-361
 
Boyce, JM Methicillin-resistantStaphylococcus aureus: detection, epidemiology, and control measures.Infect Dis Clin North Am1989;3,901-913
 
Mulligan, ME, Standiford, HC, Kauffman, CA Methicillin-resistantStaphylococcus aureus: a consensus review of the microbiology, pathogenesis, and epidemiology with implications for prevention and management.Am J Med1993;94,313-328
 
Murray, BE Vancomycin-resistant enterococci.Am J Med1997;102,284-293
 
Eliopoulos, GM Vancomycin-resistant enterococci: mechanism and clinical relevance.Infect Dis Clin North Am1997;11,851-865
 
Boyce, JM Vancomycin-resistant enterococcus: detection, epidemiology, and control measures.Infect Dis Clin North Am1997;11,367-384
 
Paterson DL, Ko WC, Mohapatra S, et al.Klebsiella pneumoniae bacteremia: impact of extended spectrum beta-lactamase (ESBL) production in a global study of 216 patients [abstract]. 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; Sept 28–Oct 1, 1997; Toronto, Ontario, Canada.
 
CDC.. Guidelines for preventing the transmission ofMycobacterium tuberculosisin health-care facilities, 1994.MMWR1994;43(No. RR-13),1-132
 
White, TC, Marr, KA, Bowden, RA Clinical, cellular, and molecular factors that contribute to antifungal drug resistance.Clin Microbiol Rev1998;11,382-402
 
CDC.. Update:Staphylococcus aureuswith reduced susceptibility to vancomycin—United States, 1997.MMWR1997;46,813-815
 
CDC.. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC).MMWR1994;44,1-13
 
Weinstein, RA Epidemiology and control of nosocomial infections in adult intensive care units.Am J Med1991;91(suppl 3B),179S-184S
 
Perl, TM Surveillance, reporting, and the use of computers. Wenzel, RP eds.Prevention and control of nosocomial infections 3rd ed.1997,127-161 Williams & Wilkins. Baltimore, MD:
 
Garner, JS Hospital Infection Control Practices Advisory Committee: guideline for isolation precautions in hospitals.Infect Control Hosp Epidemiol1996;17,53-80
 
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